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MEDSURG VATI ASSESSMENT questions with correct answers
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MEDSURG VATI ASSESSMENT questions with correct answers
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MEDSURG VATI ASSESSMENT questions withcorrect answers
A nurse is assisting with the care of four clients. Which of the following
clients is the priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 Correct Answer-- A
client who has chest tubes and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the
nurse should determine that the priority finding is the client's oxygen
saturation level, which is below the expected reference range of 95% to
100%. Therefore, the nurse should attend to this client first.
A nurse is collecting data from a client who was admitted with a
Glasgow Coma Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands Correct Answer-Nonresponsive Commands
,A client who has a GCS of less than 8 has evidence of severe head injury
and is in a comatose state. The GCS is a standardized tool that allows for
the evaluation of a client's level of consciousness. The test is divided
into three sections that evaluate eye opening, motor response, and verbal
response. The GCS ranges from a high score of 15 (fully alert) to a low
score of 3 (fully comatose).
A nurse is monitoring a client who has a pneumothorax and a chest tube
in place with a closed chest drainage system connected to low suction.
For which of the following findings should the nurse notify the charge
nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber Correct Answer--
Persistent bubbling in the water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an
air leak in the drainage system. The nurse should notify the charge nurse
of this finding.
A nurse is reinforcing teaching with a male client who has right sided
hemiparesis about
preforming ADL's. Which of the following instructions should the nurse
include in the teaching
-Comb your hair with the unaffected arm
,-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side Correct Answer-Comb your hair with the
unaffected arm
The nurse should instruct the client to brush their hair with the
unaffected arm to reduce frustration and increase independence and self-
esteem.
A nurse is collecting data from a client and auscultates intermittent high-
pitched sounds during inspiration over the lower base of the lungs. The
nurse should identify this finding as which of the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction Correct Answer-- Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves
through airway secretions. Fine crackles are intermittent, high-pitched
sounds heard more often during inspiration.
A nurse is collecting data from a client who has coronary artery disease.
Which of the following
manifestations should the nurse identify as an indication that the client
has angina ( SatA)
, - Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest Correct Answer-- Chest Discomfort
Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which
of the following clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic Correct Answer-A
client who has diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority action is to attend to a client who has
diabetes mellitus and is diaphoretic. Diaphoresis is a manifestation of
hypoglycemia and can lead to decreased cerebral function. The nurse
should check the client's blood glucose and administer a fast-acting
glucose as prescribed.
A nurse is collecting data from a client who has tuberculosis and started
combination therapy
2months ago. Which of the following diagnostic results indicates that the
client is adhering to the
medication regimen.
- A negative chest X-ray
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